Calpers Direct Deposit Authorization Form Page 2
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1
2Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page
Certification
Section 4
Signature required.
I certify I am entitled to the payment identified above. In signing this form, I authorize my payment to be sent to
my financial institution and deposited to my designated account. I authorize amounts transferred after my death
or transmitted in error to be debited from my account. Additionally, I certify that the funds received are not deposited
**To comply with new
to an account that is subject to being transferred to a foreign financial institution.**
NACHA regulations
regarding international ACH
Transactions (IAT), CalPERS
Signature of Payee
Date (mm/dd/yyyy)
will not accept requests for
or
c
I elect to view my statement online.***
electronic fund transfers (EFT)
c
I elect to receive my statement by mail.
in association with financial
institutions outside of the
territorial jurisdiction of the
United States. (The territorial
jurisdiction of the United
States includes all 50 states,
U.S. territories, U.S. military
bases and U.S. embassies
in foreign countries.) If your
entire benefit allowance will
be received by a financial
institution outside the
territorial jurisdiction of the
U.S., you will be issued a
paper check in lieu of the EFT.
Direct Deposit statements
are available online.
*** Don’t have a Username?
Register online at
my.calpers.ca.gov.
Mail to:
CalPERS Benefit Services Division
P.O. Box 942716, Sacramento, California 94229-2716
•
PERS-BSD-1199P (11/11)
Page 2 of 2
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